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A CASE OF ANENCEPHALUS.
990 support to enable them to keep up sufficient pressure upon the abdominal viscera to restore the temporary loss of functional power caused by the fluid in the cavity. Further, the pressure upon the diaphragm was beneficial in restoring the respiratory function of the lung damaged by the fluid pressure in the pleural cavity. Abdominal respiration was hindered by the binding up of the abdominal walls and respiratory action was directly stimulated as a conA physiological analogy is sequence of such hindrance. furnished in the case of advancing pregnancy : the pulmonary capacity of a woman increases under the encroachment of the enlarging uterus ; so the limitation of the abdominal cavity by strapping appears to cause the thoracic movements to be exaggerated and the respiratory powers of the lungs to be increased.
but normal lung sounds on respiration. There no evidence of actual lung disease anywhere. The heart’s action was normal. The abdomen was evidently distended and on sitting gave percussion and dulness nearly up to the umbilicus. When lying the anterior dulness sank to just above the suprapubic region in the middle line and was perceptible in the lumbar region. There was thrill on palpatory percussion. There was evidently a considerable quantity of free fluid in the resonance
was,
’
however,
peritoneal cavity. Dr. Morison saw the patient in consultation and advised that she should have complete rest. For the abdominal condition he recommended abdominal strapping in the first instance, to be followed by tapping and re-strapping if the fluid increased to any extent. Adhesive plaster in strips two inches broad was applied to the abdomen, several layers being used, until a fairly rigid casing of the abdomen was obtained. The pressure was moderate at first. The strapping was applied all over the abdomen, extending up to, but not involving, the lower ribs, so as not to interfere with respiration. Tonics were given and fresh air with nourishing food was ordered. The strapping was removed in three days and the fluid was found to have diminished in quantity, when the abdomen was re-strapped, more pressure being applied on this occasion. The treatment was continued for about three weeks, each application of strapping being allowed to remain for three or four days. The fluid gradually disappeared and on removing the last strapping the abdomen presented a normal appearance. Tenderness was felt on pressing over the former seat of pain, but no definite evidence of any lesion could be discovered. The patient improved in health and gained weight, the lung gradually cleared up, and fremitus could be felt over the former area of dulness, though at the extreme base dulness persisted, due no doubt to a thickened pleura She was ordered to live in the country and as much as possible in the open air ; iron and arsenic were continued in order to combat the anaemia which still persisted. She reported herself on July llth, 1902, when it was found that she had gained weight and had a good colour. On examination slight dulness was detected over the extreme left base and breath sounds were audible over the former area of dulness. The abdomen was now of normal appearance, no fluid being perceptible. There was slight tenderness on pressure over the former seat of pain and dulness. The patient now menstruated regularly and had done so for the previous four months. The case was regarded as being of tuberculous origin, the diagnosis being based on the following facts: 1. There was extensive pleurisy of the left side, with a large effusion in the pleural cavity, and an isolated patch of pleurisy on the right side anteriorly. 2. There were emaciation and marked anasmia. 3. Coexistent with a peritoneal lesion there were tenderness and dulness on the left side with, later, an obstinately sluggish effusion into the peritoneal cavity. Unfortunately it was impossible to demonstrate the bacillus, there being no expectoration at any period of the prolonged illness. The case resisted the ordinary methods of treatment for a considerable time, the effusion steadily increased in quantity, and the case began to look decidedly discouraging. It was only after the abdomen had been strapped that the patient began to show any sign of improvement and then she improved rapidly. Assuming that the diagnosis of tuberculous pleurisy with an accompanying tuberculous peritonitis was correct the points of interest are chiefly as follows : 1. The great value of firm abdominal strapping as a means of promoting the absorption of an excessive quantity of free fluid in the peritoneal cavity. 2. The rapid absorption of the fluid which had resisted for months the ordinary medicinal treatment. The improvement was noticed after the first application of strapping and gradually increased with each fresh application, till in three weeks the peritoneal cavity was cleared of all fluid. 3. The resulting improvement which took place in the lung condition, the resonance of the lung improving and respiratory sounds in the affected area becoming more evident. The absorption of the fluid in the peritoneal cavity was aided by the firm pressure forcing the fluid upwards towards the diaphragm which is liberally supplied with lymphatic structures. The strapping helped to restore the power of the lymphatics and to give the necessary support to enable them to deal with an abnormal accumulation of fluid ; in other words, the abdominal muscles required extra
I
Highgate,
N.
A CASE OF ANENCEPHALUS. BY W. H. MAIDLOW, M.D.
DURH., F.R.C.S. ENG.
CASES of this foetal malformation are of sufficient rarity and clinical interest to merit notice, and reflecting upon the fascinating subject of ante-natal pathology, on which Ballantyne has so well written, I venture to publish my notes of the following case. A well-developed primipara, aged 25 years, had married, There was no on April 25th, 1901, her maternal cousin. personal or family history of syphilis, alcoholism, tubercle, or of any deformity, and the stock was free from obvious "degeneracy." The patient’s last menstruation ceased on April 25th. On May 14th she"caught a chill"and about the middle of June an irate old woman asked her how her "lunatic child"was. Early in July movements were felt. For a week, on and off, in the middle of November she had some epileptoid attacks which were strongly suggestive of eclampsia, but there was no albuminuria. At this time the fundus of the uterus was one and a half inches below a line drawn across the abdomen at the level of the eleventh ribs and the movements were quite vigorous. On March 18th, 1902, the patient was awakened at 2 A. M. by the noisy rupture of the membranes, the liquor amnii deluging the bed. At 5 A.M. the abdomen was very large, head, and back to left and anterior. Per vaginam the os uteri appeared normal, its diameter being two inches and with soft margin likely to dilate without difficulty. The presentation was difficult to be sure about, for on the one hand there was bone which felt like the occipital protuberance and on the other there were three softish masses which would have answered to either a face or a breech presentation. Diagnosis was made of "something unusual." Deciding to expedite labour I applied a firm binder, withdrew half a pint of urine, washed out the rectum, fed the patient and prescribed a mixture of quinine and belladonna as an oxytocic and an anti-spasmodic respectively. At 10 A.M., however, I had to change my tactics and ordered chloral and nepenthe, as absolutely no progress had been made and no sufficient At 3.30 P.M., after five hours’ pains were resulting. good sleep, the os uteri had fully dilated, the pains were good, and the foetus was lying obliquely with its anterior ear well within reach, and affording no doubt that the vault was malformed. In spite of good pains the head did not descend through the brim, so at 4.30 P. M. it was drawn (the patient being under chloroform), after a quarter of an hour’s pulling, to the perineum, whence, also refusing to move, after another half an hour forceps were re-applied and it was easily extracted. In spite of all endeavours further expulsion seemed impossible and it remained there, tightly gripped by the perineum and encircled by the funis, for an hour whilst I sent for my partner to help me. I thought of foetal ascites or locked twins (the abdomen still being large), or possibly of a too short funis. After much difficulty my finger was able to hook under the posterior axilla and the child was delivered, with, unfortunately, a complete rupture of the perineum. Another large gush of liquor amnii preceded the birth of the placenta which was normal and easily expressed. After an hour’s rest the perineum was restored and the patient made an uneventful recovery. The child was a male, 24 inches in length and weighing 11 pounds ; the bisacromial diameter measured eight inches and the cord 22 inches. There was no neck. The base of the skull ended anteriorly at the orbital margins and
991 at the occipital protuberance. The vault consisted of membrane, in the anterior third of which were two lateral lobes and one anterior lobe united at the bases, each
posteriorly
big as a blackbird’s egg and suggestive of an encephalocele. There was no obvious cerebrum but the cerebellum and the parts below seemed normal. The feet showed fixed as
talipes equino-varus.
Had I remembered the usual associated conditions of an absent or a short neck and long bisacromial diameter-I should not have marvelled at the delay after the birth of the head. Even if the period in May was missed pathologically, unless the large size of the child be looked at as vicarious to the non-developed head, pregnancy was evidently protracted. The convulsions in November, the hydramnios, the talipes, the so-called maternal impression, and the consanguineous marriage are other interesting features of the case. In spite of the long detention the child lived for 15 minutes after birth and I might have then died after some slight convulsions. obtained more room had I amputated the head, but the absence of a neck and the proximity of the head to the vulva made this impracticable without risking a worse injury than a ruptured perineum. This might also have been avoided had I done cleidotomy. The course pursued appeared on the whole to present fewest risks to the mother. There was no maternal pelvic deformity.
anencephalus-viz.,
Ilminster. ____________________
his pipe with a match ; instantly flash and a slight report due to ignition of the gases released from the stomach. The patient’s beard and eyebrows were thoroughly singed but happily no further damage was done. It would be interesting to hear of similar cases and whether this dangerous complication of dyspepsia is at all
just
as
there
he
lighting blinding
was
were
a
common.
Eastbourne.
OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv., Proœmium.
CARDIFF INFIRMARY. A CASE OF RESECTION OF THE STERNUM FOR A SARCOMATOUS
GROWTH.
of Dr. P. RHYS GRIFFITHS.) THE number of recorded cases in which resection of the AND sternum for a malignant growth has been performed is by no MEDICAL, means large. In some cases the bone has been resected THERAPEUTICAL. because it has been involved in a malignant growth extending from neighbouring parts, but the operation is generally UNILATERAL PRESSURE ON THE THORAX AS AN performed for a primary sarcoma of the bone. It is always AID IN DIAGNOSIS. extremely difficult and often impossible to determine when the anterior mediastinum is involved, so that the proBY G. MORENO DE LA TORRE, M. D. gnosis must always be grave ; but sufficient instances have been published to show that in suitable cases resection of PNEUMONIA can usually be diagnosed with tolerable cer- the sternum for malignant disease is a very satisfactory tainty, but it occasionally happens that the physical signs operation. In the following case the disease was extensive and at the necropsy other parts of the body were found to are obscure or difficult to elicit, as, for instance, in cases of chronic pulmonary disease with emphysema, adhesions, be involved, but the patient lived for four months after the operation even though it was not found possible to remove &c., or in very corpulent patients, or in females with abnor- the whole of the local disease. mally large breasts, or when the pneumonia is central. The A man, aged 25 years, a collier, was admitted into the are sometimes in the also very Imsoll Ward of the Cardiff general symptoms misleading Infirmary under the care of young, in the very old, and in the intemperate. In all such Dr. P. R. Griffiths on March 29th, 1900, for a swelling over cases, if pain be present, however slight or vague or abnorthe sternum. Dr. Eldon Pratt stated that the man was quite it I be made as an aid available mally situated, may, think, If both hands are well and fat and able to work until seven months before to diagnosis in the following manner. some three admission. He was then attacked with applied over one side of the chest in front and pressure times daily. The vomiting lasted for a vomiting week. It was then sufficient to arrest all movement in the subjacent lung be for the first time that he noticed a swelling over the slowly exerted, when the inflammation causing the pain is breast-bone. Ever since he had been getting thinner and in that lung the pain will either disappear or, in the event of it persisting, the patient will at least breathe without weaker. At Christmas, 1899, he had an attack of influenza and was laid up for six weeks. Since then he had been discomfort. If there be inflammation in the other lung also unable to follow his occupation. The lump at this time the pain will generally continue, though its character and was of about the size of a walnut. Seven weeks If the inflammation is in an abdominal (Christmas) seat may change. before admission he had a severe cough for a week and he or and the tissues it the will continue organ surrounding pain stated that from this time the lump had been increasing will perhaps increase. I have not yet had an opportunity of in size. It had caused him no pain, rapidly testing this sign in pericarditis. By making pressure first except occasionally, when it was like apractically knife running into on one side of the thorax and then on the other it may be him. He had had no fainting or dyspnoea. His appetite possible to draw conclusions as to whether the part affected had been good. He had always been a healthy man. He is in the thorax or the abdomen, and in the former case on had had no illness except influenza. He had not had syphilis which side of the thorax it is. If pain referred to the or gonorrhoea. There was no history of a blow. On abdomen disappears when pressure is made on the thorax the inference is that the primary cause of it is some admission he was a very sallow-complexioned man, dark, He had evidently wasted a good deal. tall, and thin. pulmonary disorder. He seemed to move somewhat feebly and he looked as Cerrada del Paseo, Habana, Cuba. though he might be the subject of malignant disease. He did not complain of pain but he stated that he had an attack of pain in his chest the day before admission. On EXPLOSIVE ERUCTATIONS. examination of the chest there was found a symmetrical BY ANTONY A. MARTIN, M.D., B.S. LOND. swelling centrally placed over the steinum. The swelling was prominent in its centre and it shaded off all round, but AN elderly man under my care has been suffering for some the edge could be fairly well felt. It extended from the weeks from severe atonic dyspepsia. A marked feature of second to the seventh costal cartilages. It was hard and his case is fermentative decomposition of the contents of the tense, but in one or two places it gave the impression of fluctuation. It was firmly fixed to the sternum and could dilated stomach with frequent eructations of foul gas which The costal cartilages as well as the sternum not be moved. he says "tastes like rotten eggs." On Sept. 19th, two were somewhat raised above the general level of the chest. hours after a light breakfast, he was obliged to eructate The skin over the tumour was quite healthy and of normal
Clinical Notes:
SURGICAL, OBSTETRICAL,
(Under
the
care
but normal lung sounds on respiration. There no evidence of actual lung disease anywhere. The heart’s action was normal. The abdomen was evidently distended and on sitting gave percussion and dulness nearly up to the umbilicus. When lying the anterior dulness sank to just above the suprapubic region in the middle line and was perceptible in the lumbar region. There was thrill on palpatory percussion. There was evidently a considerable quantity of free fluid in the resonance
was,
’
however,
peritoneal cavity. Dr. Morison saw the patient in consultation and advised that she should have complete rest. For the abdominal condition he recommended abdominal strapping in the first instance, to be followed by tapping and re-strapping if the fluid increased to any extent. Adhesive plaster in strips two inches broad was applied to the abdomen, several layers being used, until a fairly rigid casing of the abdomen was obtained. The pressure was moderate at first. The strapping was applied all over the abdomen, extending up to, but not involving, the lower ribs, so as not to interfere with respiration. Tonics were given and fresh air with nourishing food was ordered. The strapping was removed in three days and the fluid was found to have diminished in quantity, when the abdomen was re-strapped, more pressure being applied on this occasion. The treatment was continued for about three weeks, each application of strapping being allowed to remain for three or four days. The fluid gradually disappeared and on removing the last strapping the abdomen presented a normal appearance. Tenderness was felt on pressing over the former seat of pain, but no definite evidence of any lesion could be discovered. The patient improved in health and gained weight, the lung gradually cleared up, and fremitus could be felt over the former area of dulness, though at the extreme base dulness persisted, due no doubt to a thickened pleura She was ordered to live in the country and as much as possible in the open air ; iron and arsenic were continued in order to combat the anaemia which still persisted. She reported herself on July llth, 1902, when it was found that she had gained weight and had a good colour. On examination slight dulness was detected over the extreme left base and breath sounds were audible over the former area of dulness. The abdomen was now of normal appearance, no fluid being perceptible. There was slight tenderness on pressure over the former seat of pain and dulness. The patient now menstruated regularly and had done so for the previous four months. The case was regarded as being of tuberculous origin, the diagnosis being based on the following facts: 1. There was extensive pleurisy of the left side, with a large effusion in the pleural cavity, and an isolated patch of pleurisy on the right side anteriorly. 2. There were emaciation and marked anasmia. 3. Coexistent with a peritoneal lesion there were tenderness and dulness on the left side with, later, an obstinately sluggish effusion into the peritoneal cavity. Unfortunately it was impossible to demonstrate the bacillus, there being no expectoration at any period of the prolonged illness. The case resisted the ordinary methods of treatment for a considerable time, the effusion steadily increased in quantity, and the case began to look decidedly discouraging. It was only after the abdomen had been strapped that the patient began to show any sign of improvement and then she improved rapidly. Assuming that the diagnosis of tuberculous pleurisy with an accompanying tuberculous peritonitis was correct the points of interest are chiefly as follows : 1. The great value of firm abdominal strapping as a means of promoting the absorption of an excessive quantity of free fluid in the peritoneal cavity. 2. The rapid absorption of the fluid which had resisted for months the ordinary medicinal treatment. The improvement was noticed after the first application of strapping and gradually increased with each fresh application, till in three weeks the peritoneal cavity was cleared of all fluid. 3. The resulting improvement which took place in the lung condition, the resonance of the lung improving and respiratory sounds in the affected area becoming more evident. The absorption of the fluid in the peritoneal cavity was aided by the firm pressure forcing the fluid upwards towards the diaphragm which is liberally supplied with lymphatic structures. The strapping helped to restore the power of the lymphatics and to give the necessary support to enable them to deal with an abnormal accumulation of fluid ; in other words, the abdominal muscles required extra
I
Highgate,
N.
A CASE OF ANENCEPHALUS. BY W. H. MAIDLOW, M.D.
DURH., F.R.C.S. ENG.
CASES of this foetal malformation are of sufficient rarity and clinical interest to merit notice, and reflecting upon the fascinating subject of ante-natal pathology, on which Ballantyne has so well written, I venture to publish my notes of the following case. A well-developed primipara, aged 25 years, had married, There was no on April 25th, 1901, her maternal cousin. personal or family history of syphilis, alcoholism, tubercle, or of any deformity, and the stock was free from obvious "degeneracy." The patient’s last menstruation ceased on April 25th. On May 14th she"caught a chill"and about the middle of June an irate old woman asked her how her "lunatic child"was. Early in July movements were felt. For a week, on and off, in the middle of November she had some epileptoid attacks which were strongly suggestive of eclampsia, but there was no albuminuria. At this time the fundus of the uterus was one and a half inches below a line drawn across the abdomen at the level of the eleventh ribs and the movements were quite vigorous. On March 18th, 1902, the patient was awakened at 2 A. M. by the noisy rupture of the membranes, the liquor amnii deluging the bed. At 5 A.M. the abdomen was very large, head, and back to left and anterior. Per vaginam the os uteri appeared normal, its diameter being two inches and with soft margin likely to dilate without difficulty. The presentation was difficult to be sure about, for on the one hand there was bone which felt like the occipital protuberance and on the other there were three softish masses which would have answered to either a face or a breech presentation. Diagnosis was made of "something unusual." Deciding to expedite labour I applied a firm binder, withdrew half a pint of urine, washed out the rectum, fed the patient and prescribed a mixture of quinine and belladonna as an oxytocic and an anti-spasmodic respectively. At 10 A.M., however, I had to change my tactics and ordered chloral and nepenthe, as absolutely no progress had been made and no sufficient At 3.30 P.M., after five hours’ pains were resulting. good sleep, the os uteri had fully dilated, the pains were good, and the foetus was lying obliquely with its anterior ear well within reach, and affording no doubt that the vault was malformed. In spite of good pains the head did not descend through the brim, so at 4.30 P. M. it was drawn (the patient being under chloroform), after a quarter of an hour’s pulling, to the perineum, whence, also refusing to move, after another half an hour forceps were re-applied and it was easily extracted. In spite of all endeavours further expulsion seemed impossible and it remained there, tightly gripped by the perineum and encircled by the funis, for an hour whilst I sent for my partner to help me. I thought of foetal ascites or locked twins (the abdomen still being large), or possibly of a too short funis. After much difficulty my finger was able to hook under the posterior axilla and the child was delivered, with, unfortunately, a complete rupture of the perineum. Another large gush of liquor amnii preceded the birth of the placenta which was normal and easily expressed. After an hour’s rest the perineum was restored and the patient made an uneventful recovery. The child was a male, 24 inches in length and weighing 11 pounds ; the bisacromial diameter measured eight inches and the cord 22 inches. There was no neck. The base of the skull ended anteriorly at the orbital margins and
991 at the occipital protuberance. The vault consisted of membrane, in the anterior third of which were two lateral lobes and one anterior lobe united at the bases, each
posteriorly
big as a blackbird’s egg and suggestive of an encephalocele. There was no obvious cerebrum but the cerebellum and the parts below seemed normal. The feet showed fixed as
talipes equino-varus.
Had I remembered the usual associated conditions of an absent or a short neck and long bisacromial diameter-I should not have marvelled at the delay after the birth of the head. Even if the period in May was missed pathologically, unless the large size of the child be looked at as vicarious to the non-developed head, pregnancy was evidently protracted. The convulsions in November, the hydramnios, the talipes, the so-called maternal impression, and the consanguineous marriage are other interesting features of the case. In spite of the long detention the child lived for 15 minutes after birth and I might have then died after some slight convulsions. obtained more room had I amputated the head, but the absence of a neck and the proximity of the head to the vulva made this impracticable without risking a worse injury than a ruptured perineum. This might also have been avoided had I done cleidotomy. The course pursued appeared on the whole to present fewest risks to the mother. There was no maternal pelvic deformity.
anencephalus-viz.,
Ilminster. ____________________
his pipe with a match ; instantly flash and a slight report due to ignition of the gases released from the stomach. The patient’s beard and eyebrows were thoroughly singed but happily no further damage was done. It would be interesting to hear of similar cases and whether this dangerous complication of dyspepsia is at all
just
as
there
he
lighting blinding
was
were
a
common.
Eastbourne.
OF
HOSPITAL
PRACTICE,
BRITISH AND FOREIGN. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv., Proœmium.
CARDIFF INFIRMARY. A CASE OF RESECTION OF THE STERNUM FOR A SARCOMATOUS
GROWTH.
of Dr. P. RHYS GRIFFITHS.) THE number of recorded cases in which resection of the AND sternum for a malignant growth has been performed is by no MEDICAL, means large. In some cases the bone has been resected THERAPEUTICAL. because it has been involved in a malignant growth extending from neighbouring parts, but the operation is generally UNILATERAL PRESSURE ON THE THORAX AS AN performed for a primary sarcoma of the bone. It is always AID IN DIAGNOSIS. extremely difficult and often impossible to determine when the anterior mediastinum is involved, so that the proBY G. MORENO DE LA TORRE, M. D. gnosis must always be grave ; but sufficient instances have been published to show that in suitable cases resection of PNEUMONIA can usually be diagnosed with tolerable cer- the sternum for malignant disease is a very satisfactory tainty, but it occasionally happens that the physical signs operation. In the following case the disease was extensive and at the necropsy other parts of the body were found to are obscure or difficult to elicit, as, for instance, in cases of chronic pulmonary disease with emphysema, adhesions, be involved, but the patient lived for four months after the operation even though it was not found possible to remove &c., or in very corpulent patients, or in females with abnor- the whole of the local disease. mally large breasts, or when the pneumonia is central. The A man, aged 25 years, a collier, was admitted into the are sometimes in the also very Imsoll Ward of the Cardiff general symptoms misleading Infirmary under the care of young, in the very old, and in the intemperate. In all such Dr. P. R. Griffiths on March 29th, 1900, for a swelling over cases, if pain be present, however slight or vague or abnorthe sternum. Dr. Eldon Pratt stated that the man was quite it I be made as an aid available mally situated, may, think, If both hands are well and fat and able to work until seven months before to diagnosis in the following manner. some three admission. He was then attacked with applied over one side of the chest in front and pressure times daily. The vomiting lasted for a vomiting week. It was then sufficient to arrest all movement in the subjacent lung be for the first time that he noticed a swelling over the slowly exerted, when the inflammation causing the pain is breast-bone. Ever since he had been getting thinner and in that lung the pain will either disappear or, in the event of it persisting, the patient will at least breathe without weaker. At Christmas, 1899, he had an attack of influenza and was laid up for six weeks. Since then he had been discomfort. If there be inflammation in the other lung also unable to follow his occupation. The lump at this time the pain will generally continue, though its character and was of about the size of a walnut. Seven weeks If the inflammation is in an abdominal (Christmas) seat may change. before admission he had a severe cough for a week and he or and the tissues it the will continue organ surrounding pain stated that from this time the lump had been increasing will perhaps increase. I have not yet had an opportunity of in size. It had caused him no pain, rapidly testing this sign in pericarditis. By making pressure first except occasionally, when it was like apractically knife running into on one side of the thorax and then on the other it may be him. He had had no fainting or dyspnoea. His appetite possible to draw conclusions as to whether the part affected had been good. He had always been a healthy man. He is in the thorax or the abdomen, and in the former case on had had no illness except influenza. He had not had syphilis which side of the thorax it is. If pain referred to the or gonorrhoea. There was no history of a blow. On abdomen disappears when pressure is made on the thorax the inference is that the primary cause of it is some admission he was a very sallow-complexioned man, dark, He had evidently wasted a good deal. tall, and thin. pulmonary disorder. He seemed to move somewhat feebly and he looked as Cerrada del Paseo, Habana, Cuba. though he might be the subject of malignant disease. He did not complain of pain but he stated that he had an attack of pain in his chest the day before admission. On EXPLOSIVE ERUCTATIONS. examination of the chest there was found a symmetrical BY ANTONY A. MARTIN, M.D., B.S. LOND. swelling centrally placed over the steinum. The swelling was prominent in its centre and it shaded off all round, but AN elderly man under my care has been suffering for some the edge could be fairly well felt. It extended from the weeks from severe atonic dyspepsia. A marked feature of second to the seventh costal cartilages. It was hard and his case is fermentative decomposition of the contents of the tense, but in one or two places it gave the impression of fluctuation. It was firmly fixed to the sternum and could dilated stomach with frequent eructations of foul gas which The costal cartilages as well as the sternum not be moved. he says "tastes like rotten eggs." On Sept. 19th, two were somewhat raised above the general level of the chest. hours after a light breakfast, he was obliged to eructate The skin over the tumour was quite healthy and of normal
Clinical Notes:
SURGICAL, OBSTETRICAL,
(Under
the
care